Two thousand RISE National attendees took over the Music City Center in Nashville on Monday morning, the first day of the main conference, to hear back-to-back presentations from the Office of Inspector General (OIG), Department of Justice (DOJ), and Centers for Medicare & Medicaid Services (CMS).

Inspector general on how ma plans can cultivate trust 

Inspector General Christi A. Grimm, the sixth inspector general of the U.S. Department of Health and Human Services, emphasized the need to cultivate trust through a culture of compliance.

Managed care, she said, possesses tremendous appeal but only if it delivers on its promised outcomes. In many ways, she said, it is falling short. Many seniors in Medicare Advantage (MA) plans have complained that plans are denying medically necessary care, making patients jump over unnecessary hoops, and prioritizing profit over care. “This is not the word of mouth you are looking for,” she said.

She said prior authorization and risk adjustment are examples of where plans are falling short. Prior authorization is not working as intended, Grimm said, adding that more than 10 percent of prior authorization denials were for care requests that did meet Medicare coverage rules. OIG audits reveal that plans often submit claims with potentially inaccurate diagnoses and in some cases, purposeful upcoding, leading to overpayments.

The OIG is also trying to combat fraud against MA plans. “Fraudsters pay attention to industry trends and where the money is,” she said, adding that durable medical equipment (DME) is one area that is especially vulnerable to fraud. Indeed, from 2020-2023, overall DME billing in MA increased 59 percent. One emerging risk area is DME suppliers that do not participate in traditional Medicare. Thousands only bill MA.

She urged plans to make sure they know whom they are doing business with and have policies and procedures in place to screen for risky suppliers.

DOJ on the False Claims Act and consequences of financial fraud

Next, DOJ’s Edward C. Crooke, assistant director, civil division, fraud section, explained the role of the office, which is responsible for investigating and litigating cases involving financial fraud against the United States. The primary tool it uses is the False Claims Act (FCA).

Since 2013, civil FCA settlements and judgements have totaled $36.6 billion in civil cases. More than $25 billion of those settlements and judgements were for civil health care fraud cases.

Whistleblower provisions of the FCA also allow private citizens to make complaints. These whistleblowers can be current employers, former employers, vendors, customers, or industry experts looking at data. Whistleblowers have incentives to come forward. They are entitled to share in the recovery the government gets. If the DOJ intervenes in the case, they are entitled to 25 percent, and if the DOJ declines and whistleblowers go forward with the case, they are entitled up to 30 percent.

In 2023, the government paid $350 million to whistleblowers who filed complaints under the FCA, he said.

Examples of cases the DOJ has pursued against MA plans include kickbacks to brokers and other referral sources and home visits, which has been a way to include additional diagnoses. He encouraged attendees to look at the risk factors that OIG and CMS have identified in connection with home visits, such as people who go to the home who aren’t providers, diagnoses not communicated to providers or the member themselves, diagnoses that can’t be identified by test equipment, cases in which it’s unclear whether the provider even went to the member’s home, and too many home visits conducted in one day to be reasonable.  

Another focus area is MA plans’ denial of medically necessary care. MA organizations are obligated to provide services covered by Medicare and when they don’t provide that care, it raises program integrity and FCA concerns.

Crooke encouraged providers and MA plans to invest in their compliance programs and look specifically at the areas that the DOJ investigates. “We issue press releases every time there is a settlement,” he said. “Be thinking about what we are looking at and don’t wait until we come knocking at your door.”

Finally, he said, if there is an issue within your organization, take advantage of the self-disclosure provisions that DOJ and OIG make available. They watchdogs have flexibility when organizations come to them on their own. “We are not suggesting plans shouldn’t be making money. It’s a for-profit industry. What we are concerned about is when there is fraud in connection with claims submitted and that’s where we become involved,” he said.

CMS offers an overview of HHS-operated risk adjustment 

CMS’ Allison Wiley, health insurance specialist, and Daphne Letherer, management and program analyst, both from the Center for Consumer Information and Insurance, wrapped up the morning sessions with an overview of HHS-operated risk adjustment, including the 2025 Payment Notice Proposed Rule, an overview of 2023 benefit year risk adjustment, and the 2022 and 2023 benefit years HHS-RADV.

They also discussed the ongoing plans to update HHS-RADV protocols to improve use, including separating audit executive guidance so it is specific to each review.